Common use of Voluntary Disenrollment Clause in Contracts

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative at your center. You will be asked to sign a Department approved disenrollment form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective the first day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment. You may not disenroll from LIFE at a Social Security office. Choosing to enroll in any other Medicare or Medical Assistance Program benefit, including the Hospice benefit after you enrolled in LIFE, is considered a voluntary disenrollment from LIFE. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Involuntary Disenrollment Your LIFE Provider can terminate your benefits, if: • You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Note: In Pennsylvania, individuals who reside in personal care boarding homes are not nursing home eligible. Therefore, any individual who relocates to a personal care boarding home will be involuntarily disenrolled from the LIFE Program. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangements. An independent review entity will review the involuntary disenrollment. If you are disenrolled due to failure to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverage.

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative at your center. You will be asked need to sign a Department approved disenrollment form (see Appendix H)form, which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective the first day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment. You may not disenroll from LIFE at a Social Security office. Choosing to enroll in any other Medicare or Medical Assistance Program program benefit, including the Hospice benefit after you enrolled in LIFE, is considered a voluntary disenrollment from LIFE. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Involuntary Disenrollment Your LIFE Provider can terminate your benefits, if: • You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, pay or fail to make satisfactory arrangements to pay, pay any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process LIFE after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Note: In Pennsylvania, individuals who reside in personal care boarding homes are not nursing home eligible. Therefore, any individual who relocates to a personal care boarding home will be involuntarily disenrolled from the LIFE Program. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar 30-day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar 30-day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangements. An independent review entity will review the involuntary disenrollment. If you are disenrolled due to failure to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverage.

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative at your center. You will be asked to sign a Department approved disenrollment form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective the first day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment. You may not enroll or disenroll from LIFE at a Social Security office. Choosing to enroll in any other Medicare or Medical Assistance Program benefit, including the Hospice benefit benefit, after you enrolled enrolling in LIFE, LIFE is considered a voluntary disenrollment from LIFE. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Involuntary Disenrollment Your LIFE Provider can terminate your benefits, if: • You move out of the LIFE service areaarea or are out of the service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet nursing facility level of care as determined by the eligibility requirements for the programDepartment and are deemed not eligible. • The LIFE program agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Note: In Pennsylvania, individuals who reside in personal care boarding homes are not nursing home eligible. Therefore, any individual who relocates to a personal care boarding home will be involuntarily disenrolled from the LIFE Program. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 30-calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 30-calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department or the Department’s designee to reinstate the participant you in other Medicare and Medical Assistance Programs for which the participant is you are eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangements. An independent review entity will review the involuntary disenrollmentappeal. If you are disenrolled due to failure to pay the premiumyour premium or payment toward cost of care, you can re-enroll remain enrolled simply by paying the amount owed in full. Provided you make this payment full before the effective date of your disenrollment, there will be with no break in coverage.

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative your social worker. You may disenroll from {PACE Organization} without cause at your centerany time. You will be asked need to sign a Department approved disenrollment “Disenrollment Form”. This form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective {PACE Organization} after midnight on the first last day of the month following the date your LIFE Provider receives notice of your voluntary disenrollmentmonth. You Please note that you may not disenroll from LIFE {PACE Organization} at a Social Security office. Choosing to enroll in any other Medicare or Medical Assistance Program benefit, including the Hospice benefit after you enrolled in LIFE, is considered a voluntary disenrollment from LIFE. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Involuntary Disenrollment Your LIFE Provider can We may terminate your benefits, enrollment with {PACE Organization} if: • You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the {PACE Organization} service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Note: In Pennsylvania, individuals who reside in personal care boarding homes are not nursing home eligible. Therefore, any individual who relocates to a personal care boarding home will be involuntarily disenrolled from the LIFE Program. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in {include zip codes or other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan identifying information here} or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangementsapproval (see CHAPTER 6). An independent review entity • You engage in disruptive or threatening behavior, i.e. your behavior jeopardizes the health or safety of yourself or others or you consistently refuse to comply with the terms of your Plan of Care or Enrollment Agreement, when you have decision-making capacity. Disenrollment under these circumstances is subject to prior approval by the DHCS and will review be sought in the event that you display disruptive interference with care planning or threatening behavior which interferes with the quality of PACE services provided to you and other PACE Participants. • You are determined to no longer meet the Medi-Cal Nursing Home level of care criteria and are not deemed eligible. • You fail to pay or fail to make satisfactory arrangements to pay any premium due to {PACE Organization} within the 30-day period specified in any Cancellation Notice (see CHAPTER 9). • The agreement between {PACE Organization}, the Centers for Medicare and Medicaid Services and the DHCS is not renewed or is terminated. • {PACE Organization} is unable to offer health care services due to the loss of our State licenses or contracts with outside providers. All rights to benefits will stop at midnight on the last day of the month following a voluntary or involuntary disenrollment. If you are disenrolled disenrollment (except in the case of termination due to failure to pay fees owed, see CHAPTER 9). We will coordinate the premiumdisenrollment date between Medicare and Medi-Cal, if you can reare eligible for both programs. You are required to use {PACE Organization} services (except for Emergency Services and Urgent Care provided outside our service area) until termination becomes effective. If you are hospitalized or undergoing a course of treatment at the time your disenrollment becomes effective, {PACE Organization} has the responsibility for service provision until you are reinstated with Medicare and Medi-enroll simply Cal benefits (according to your entitlement and eligibility). CHAPTER 11 RENEWAL PROVISIONS Your coverage by paying the amount owed in full{PACE Organization} is continuous indefinitely (with no need for renewal). Provided you make this payment before the effective date of disenrollmentHowever, there your coverage will be no break in coverage.terminated if:

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative the social worker at your PACE center. You will be asked to sign a Department approved disenrollment form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective the first day of the month following the date your LIFE Provider receives notice of your voluntary disenrollment. You may not disenroll from LIFE AllCare PACE at a any Social Security office. Choosing You will need to sign a Disenrollment Form. This form will indicate that you are no longer entitled to services through AllCare PACE as of the date when your disenrollment is effective. Your social worker will confirm this date and assist you in returning to the fee-for-service Medicare and/or Medicaid system. It is to your benefit to provide 30-day notice of your intent to disenroll. This will allow time for your health and social services to be appropriately coordinated and medical care established with another provider. If, after enrolling as an AllCare PACE participant, you elect to enroll in any other Medicare or Medical Assistance Program Medicaid plan or optional benefit, including Prescription Drug Coverage or a Hospice Program, your enrollment in the Hospice benefit after you enrolled in LIFE, is other plan will be considered a voluntary disenrollment from LIFE. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFEAllCare PACE. Involuntary Disenrollment Your LIFE Provider AllCare PACE can terminate your benefitsbenefits by notifying you in writing of our intent to disenroll you, if: • You move out of the LIFE our designated service area. • You consistently do not comply with your individual care plan and/or terms are out of this agreement and are competent to make decisions our designated service area for yourself. • You or your caregiver engage in disruptive or threatening behaviormore than 30 days without prior approved arrangements. • You fail to pay, pay your monthly private pay premiums within a 30 day grace period or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, pay your premiums. • Your behavior threatens your health and safety or any amount due under the post-eligibility treatment health and safety of income process after a 30-day grace periodothers and cannot be managed even with the support of AllCare PACE. • You are out of the service area accepted for more than 30 consecutive days without prior approval from your LIFE Provideradmission to a state psychiatric hospital. • You are admitted to an Enhanced Care Facility (ECF). Enhanced care is designed to provide 24 hour supervision and support to eligible individuals who demonstrate challenging behaviors and psychiatric symptoms. • You become incarcerated • You no longer meet state eligibility criteria and the eligibility requirements for the county or state case manager does not believe that disenrollment will result in deterioration of your health. • You attempt to buy or sell methadone or other controlled substances, resulting in discharge from a contracted methadone maintenance or substance abuse treatment program. • The agreement with the CMS and the Department is terminated. • LIFE AllCare PACE loses the contracts and/or licenses enabling it to offer health care services. Note: In Pennsylvania, individuals who reside in personal care boarding homes are • AllCare PACE’s agreement with Medicare or Medicaid is not nursing home eligiblerenewed or is terminated. Therefore, • AllCare Health determines not to continue the AllCare PACE program. AllCare PACE must receive approval from Oregon Aging and People with Disabilities to disenroll any individual who relocates to a personal care boarding home will be involuntarily disenrolled from the LIFE Programparticipant. Before If you are involuntarily disenrolled from LIFEdisenrolled, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your effective date of disenrollment will be effective and termination of AllCare PACE benefits is the first day of the month following month. This may change if the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for interdisciplinary team determines a longer time frame (no more than 30 days without prior approved arrangementsdays) is needed to ensure a smooth transition. An independent review entity will review the involuntary disenrollment. If you are disenrolled due to failure to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverage.Exceptions include:

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative your social worker. You may disenroll from FHCN PACE without cause at your centerany time. You will be asked to sign a Department approved disenrollment “Disenrollment Form”. This form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFEFHCN PACE after midnight on the last day of the month. You may voluntarily disenroll from LIFE without cause at any time. Your The effective date of your disenrollment will be effective the first day of the month following the date we receive your LIFE Provider receives notice of your voluntary disenrollmentdisenrollment notification. You Please note that you may not enroll or disenroll from LIFE FHCN PACE at a Social Security office. Choosing to enroll in any other Medicare or Medical Assistance Program benefit, including the Hospice benefit after you enrolled in LIFE, is considered a voluntary disenrollment from LIFE. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Involuntary Disenrollment Your LIFE Provider can We may terminate your benefits, enrollment with FHCN PACE if: • ● You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the FHCN PACE service area for more than 30 consecutive days without prior approval from your LIFE Provider. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Note: In Pennsylvania, individuals who reside in personal care boarding homes are not nursing home eligible. Therefore, any individual who relocates to a personal care boarding home will be involuntarily disenrolled from the LIFE Program. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first day of the month following the month in which your 30 calendar day advance notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangementsapproval (see CHAPTER 6). An independent review entity ● You or your caregiver engage in disruptive or threatening behavior, i.e., your behavior jeopardizes the health or safety of yourself or others or you consistently refuse to comply with the terms of your Plan of Care or Enrollment Agreement, when you have decision-making capacity. Disenrollment under these circumstances is subject to prior approval by the DHCS and will review be sought in the event that you or your caregiver display disruptive interference with care planning or threatening behavior that interferes with the quality of PACE services provided to you and other PACE Participants. ● You are determined to no longer meet the Medi-Cal Nursing Home level of care criteria and are not deemed eligible. ● You fail to pay or fail to make satisfactory arrangements to pay any premium due to FHCN PACE, any applicable Medicaid spend down liability, or any amount due under the post- eligibility treatment of income process, within the 30-day period specified in any Disenrollment Notice (see CHAPTER 9). ● The agreement between FHCN PACE, the Centers for Medicare and Medicaid Services and the DHCS is not renewed or is terminated. ● FHCN PACE is unable to offer health care services due to the loss of our state licenses or contracts with outside providers. All rights to benefits will stop at midnight on the last day of the month following a voluntary or involuntary disenrollment. We will coordinate the disenrollment date between Medicare and Medi-Cal if you are eligible for both programs. You are required to use FHCN PACE services (except for Emergency Services and Urgent Care provided outside our service area) and to pay the monthly fee, if applicable, until disenrollment becomes effective. FHCN PACE will continue to provide all necessary services until the disenrollment is effective. If you are disenrolled due hospitalized or undergoing a course of treatment at the time your disenrollment becomes effective, FHCN PACE has the responsibility for service provision until you are reinstated with Medicare and Medi-Cal benefits (according to failure to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverageyour entitlement and eligibility).

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative your social worker. You may disenroll from CEI PACE without cause at your centerany time. You will be asked need to sign a Department approved disenrollment “Disenrollment Form.” This form (see Appendix H), which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective CEI PACE after midnight on the first last day of the month following the date before your LIFE Provider receives notice of your voluntary disenrollment. You may not disenroll from LIFE at a Social Security office. Choosing to enroll in any other Medicare or Medical Assistance Program benefit, including the Hospice benefit after you enrolled in LIFE, is considered a voluntary disenrollment from LIFE. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFEdate. Involuntary Disenrollment Your LIFE Provider can We may terminate your benefits, enrollment with CEI PACE if: • You move out of the LIFE CEI PACE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Providerthe interdisciplinary team. • You engage in disruptive or threatening behavior that interferes with the quality of PACE services provided to you or other PACE Participants, i.e., your behavior jeopardizes the health or safety of yourself or others. • You consistently refuse to comply with the terms of your Care Plan or Enrollment Agreement, when you have decision-making capacity. • You are determined to no longer meet the eligibility requirements Medi-Cal Nursing Home level of care criteria and are deemed not eligible for PACE. • You fail to pay or fail to make satisfactory arrangements to pay any amount due to CEI PACE within the programperiod specified in any Loss of Medi-Cal Eligibility and/or Failure to Pay Monthly Premium letter (see CHAPTER 9). • The agreement with between CEI PACE, the CMS Centers for Medicare and Medicaid Services, and the Department DHCS is not renewed or is terminated. • LIFE loses the contracts and/or licenses enabling it CEI PACE is unable to offer health care servicesservices due to the loss of our State licenses or contracts with outside providers. Note: In Pennsylvania, individuals who reside in personal care boarding homes are not nursing home eligibleInvoluntary disenrollment requires advance notice. Therefore, any individual who relocates All rights to a personal care boarding home benefits will be involuntarily disenrolled from stop at midnight on the LIFE Program. Before you are involuntarily disenrolled from LIFE, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be effective the first last day of the month following the month in which your 30 calendar day advance end of the notice of period. We will coordinate the disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other between Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal Medi-Cal, if you are involuntary disenrolled eligible for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing both programs. You are required to pay or make satisfactory arrangements to pay, or if you are out of the use CEI PACE services (except for Emergency Services and Urgent Care provided outside our service area for more than 30 days without prior approved arrangements. An independent review entity will review the involuntary disenrollmentarea) until termination becomes effective. If you are disenrolled due hospitalized or undergoing a course of treatment at the time your disenrollment becomes effective, CEI PACE has the responsibility for service provision until you are reinstated with Medicare and Medi-Cal benefits (according to failure your entitlement and eligibility). CEI will work with you to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before the effective date of resolve any problems that might lead to a disenrollment, there will be no break in coverageeither voluntary or involuntary. Please discuss your unresolved concerns with your social worker, home care nurse, or center director.

Voluntary Disenrollment. If you wish to cancel your benefits by disenrolling, you should discuss this with a program representative at your center. You will be asked need to sign a Department approved disenrollment form (see Appendix H)Disenrollment Form, which will indicate that you will no longer be entitled to services through LIFE. You may voluntarily disenroll from LIFE without cause at any time. Your disenrollment will be effective the first day of the month following the date Saint Xxxxxxx LIFE receives your LIFE Provider receives notice of your voluntary disenrollment. You may not disenroll from LIFE at a Social Security office. Choosing to enroll in any other Medicare or Medical Assistance Program prepayment plan or optional benefit, including the Hospice hospice benefit after you enrolled in LIFE, is considered a voluntary disenrollment from LIFE. Your social worker will assist you in returning to the appropriate Medicare and/or Medicare/Medical Assistance Program. The Medicare or Medical Assistance Program program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Involuntary Disenrollment Your LIFE Provider can terminate your benefits, if: • You move out of the LIFE service area. • You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You or your caregiver engage engages in disruptive or threatening behavior. Disruptive or threatening behavior refers to behavior which jeopardizes the health or safety of the participant or others; individual is competent and non-compliant with individual care plans and/or terms of this agreement. • You fail to pay, pay or fail to make satisfactory arrangements to pay, pay any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process LIFE after a 30-day grace period. • You are out of the service area for more than 30 consecutive days without prior approval from your LIFE Providerapproved arrangements. • You no longer meet the eligibility requirements for the program. • The agreement with the CMS federal and the Department state government is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Note: In Pennsylvania, individuals who reside in personal care boarding homes are not nursing home eligible. Therefore, any individual who relocates to a personal care boarding home will be involuntarily disenrolled from the LIFE Program. Before you are involuntarily disenrolled from LIFE, the Department must approve the Your involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your disenrollment will be is effective on the first day of the month following that begins 30 days after the month in which your 30 calendar day advance the program sends you notice of disenrollment ends. Until the date enrollment is terminated, you must continue to use the LIFE organization services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging you or your caregiver in disruptive or threatening behavior, failing to pay or make satisfactory arrangements arrangement to pay, or if you are out of the service area for more than 30 days without prior approved arrangements. An independent review entity impartial party will review the involuntary disenrollment. 15 If you are disenrolled due to failure to pay the premiummonthly fee, you can re-enroll simply by paying the amount owed monthly fee in full. Provided you make this payment before the effective date of disenrollment, there will be no break in coverage.

Voluntary Disenrollment. You can request to be voluntarily disenrolled from MetroPlus Managed Long Term Care at any time for any reason. You may disenroll from, or leave, the Plan for any reason by giving a notice in writing or verbally. If your notice is given verbally, MetroPlus Managed Long Term Care will confirm the notice with you wish in writing. To leave MetroPlus Managed Long Term Care you must let us know that you want to cancel your benefits by disenrollingdisenroll. MetroPlus Managed Long Term Care will contact you or the person you trust to find out the reason you no longer want to be part of the Plan, but you should discuss this with do not need to give a program representative at your centerreason if you do not want to. You will be asked to sign a Department approved disenrollment request form. This form (see Appendix H)will let you know a tentative date of disenrollment, or the date in which will indicate that you will no longer be entitled to get services through LIFEthough MetroPlus Managed Long Term Care. You may voluntarily disenroll from LIFE without cause at any time. Your MetroPlus Managed Long Term Care will forward your disenrollment will be effective the first day of the month following the date request to New York Medicaid CHOICE to process your LIFE Provider receives notice of your voluntary disenrollment. You may not disenroll from LIFE at a Social Security office. Choosing to enroll in any other Medicare or Medical Assistance Program benefit, including the Hospice benefit after you enrolled in LIFE, is considered a voluntary disenrollment from LIFE. Your social worker will assist you in returning to the appropriate Medicare and/or Medical Assistance Program. The Medicare or Medical Assistance Program you enroll into upon disenrollment from LIFE may not provide you with the full range of services available to you through LIFE. Involuntary Disenrollment Your LIFE Provider can terminate MetroPlus Health Plan will disenroll you involuntarily (without your benefits, if: • You move out consent) for any of the LIFE following reasons:  You no longer live in the service area. • ;  You consistently do not comply with your individual care plan and/or terms of this agreement and are competent to make decisions for yourself. • You enroll in another Medicaid MLTC, BCHS or your caregiver engage in disruptive or threatening behavior. • You fail to pay, or fail to make satisfactory arrangements to pay, any premium due to LIFE, any applicable Medical Assistance spend down, or any amount due under the post-eligibility treatment of income process after a 30-day grace period. • OPWDD Day Treatment Program;  You are out of absent from the service area for more than 30 consecutive days;  You are hospitalized for 45 consecutive days without prior approval or have entered an OMH, OPWDD or OASAS residential program for 45 days or more;  You clinically require nursing home care, but are not eligible for such care under the Medicaid program’s institutional rules;  You cannot remain safely at home or in your community;  You do not require Managed Long Term Care services from MetroPlus for at least 120 days as determined by your LIFE Providerlast reassessment;  You are no longer eligible to receive New York State Medicaid benefits;  You do not pay for/or make satisfactory arrangements approved by MetroPlus Managed Long Term Care to pay spenddown amount owed to MetroPlus Health Plan after a (30) thirty day grace period;  You knowingly fail to complete and submit any necessary consents or releases as requested by MetroPlus Health Plan;  You give MetroPlus Health Plan false information that deceives the Plan or you engage in fraudulent conduct regarding any substantive or major aspect of your plan membership;  You, your family member or informal caregiver participate in any activity which jeopardizes the environment, engages in conduct or behavior which can jeopardize your health, safety or the health or safety of others. •  Your physician refuses to collaborate with MetroPlus on developing and implementing your plan of care and you do not wish to change providers.  You are not eligible for MLTC because you have been assessed as no longer demonstrating a functional or clinical need for community-based long term care services or, for non-dual eligible Enrollees, no longer meet the eligibility requirements for the program. • The agreement with the CMS and the Department is terminated. • LIFE loses the contracts and/or licenses enabling it to offer health care services. Note: In Pennsylvania, individuals who reside in personal care boarding homes are not nursing home eligiblelevel of care as determined using the assessment tool prescribed by the Department. Therefore, any individual who relocates to a personal care boarding home will An Enrollee whose sole service is identified as Social Day Care must be involuntarily disenrolled from the LIFE ProgramMLTC plan. Before MetroPlus Health Plan shall provide the LDSS or entity designated by the Department the results of its assessment and recommendations regarding disenrollment within five (5) business days of the assessment making such determination. Any involuntary disenrollment requires approval from New York Medicaid CHOICE (Maximus), if approved New York Medicaid CHOICE (Maximus) will notify you are involuntarily disenrolled from LIFEin writing the effective date of your disenrollment and your fair hearing rights. If you have Medicaid, the Department must approve the involuntary disenrollment. You will then be provided with a 30 calendar day written notice by your LIFE Provider. Your effective date of disenrollment from MetroPlus will be effective the first day of the month following the month in which your 30 calendar day advance notice the disenrollment request is received and is processed by the LDSS/HRA. Generally, a signed request form must be received by MetroPlus by the 15th of the month for a disenrollment endsto become effective the next month. Until the date enrollment is terminated, you must MetroPlus will continue to use the LIFE organization provide services and remain liable for any premiums, and the LIFE organization must continue to furnish all needed services. Before disenrollment, the LIFE organization will make appropriate referrals and ensure medical records are made available to new providers within 30 calendar days, and work with CMS and the Department to reinstate the participant in other Medicare and Medical Assistance Programs for which the participant is eligible. Your involuntary disenrollment will automatically be considered an appeal if you are involuntary disenrolled for not complying with your care plan or meeting conditions of participation, engaging in disruptive or threatening behavior, failing to pay or make satisfactory arrangements to pay, or if you are out of the service area for more than 30 days without prior approved arrangements. An independent review entity will review the involuntary disenrollment. If you are disenrolled due to failure to pay the premium, you can re-enroll simply by paying the amount owed in full. Provided you make this payment before until the effective date of disenrollment, there will be no break in coveragedisenrollment date.